THE ABDOMINAL VISCERA. 1417 



apex of the heart. The greater curvature crosses behind the left costal margin 

 opposite the tip of the ninth costal cartilage, that is to say, where the transpyloric 

 line intersects the left lateral line. The lowest part of the great curvature, 

 situated generally in the median plane, extends down to, or a little above, the infra- 

 costal plane, about two inches above the umbilicus. The lesser curvature and the 

 adjacent part of the anterior wall of the stomach are overlapped by the anterior 

 margin of the liver. 



Radiography of Stomach. Radiograms of the stomach, taken after a "bismuth 

 meal," show that the form and position of the stomach in the living subject differ 

 considerably from that which it presents in the cadaver. 



In the cadaver, owing to loss of muscular tone, it presents itself as a more 

 or less empty pear-shaped bag with collapsed and flaccid walls. The same applies 

 to a large extent to the stomach as seen in the operating room, its normal tonicity 

 being almost entirely held in abeyance by the anaesthetic. 



In the living subject, the form and position of the stomach are found to vary 

 not only according to the amount of food it contains, but also according to 

 whether the patient occupies the erect or the recumbent posture. The most reliable 

 as well as the most useful, information regarding the form, the position, and the 

 motor activity of the stomach is obtained by " screen " examinations and radiograms 

 taken with the patient in the erect posture. When examined in this way, after 

 partly filling the stomach with a " bismuth meal," the organ is seen to possess a 

 distinctly J -shaped form. The stem of the J, which is represented by the body of 

 the stomach, lies immediately and entirely to the left of the vertebral column. The 

 fundus, which is slightly more expanded than the body, reaches up to the left cupola 

 of the diaphragm ; it is represented in the skiagram as a light semilunar shadow, 

 the horizontal inferior margin of which corresponds to the superior limit of the 

 bismuth. This clear semilunar area is due to the rising up of the gaseous contents 

 of the stomach to the highest part of the cavity. The cardiac orifice is seen to lie 

 opposite the left side of the fibre-cartilage between the tenth and eleventh thoracic 

 vertebrae. The shadow of the curved pyloric portion of the stomach, after crossing 

 the left side of the vertebral column opposite the third and fourth lumbar vertebrae, 

 ascends as the pyloric canal to join the duodenum at or a little to the right of the 

 median plane, opposite the second (not infrequently the third) lumbar vertebra. 

 The pylorus itself is represented by a light disc due to a break in the continuity 

 of the bismuth, caused by contraction of the pyloric sphincter. The lowest portion 

 of the greater curvature, which generally lies at or a little to the left of the median 

 plane, reaches, in the erect posture, down to the level of the middle or inferior border 

 of the fourth lumbar vertebra, or, in other words, to the umbilicus and the highest 

 part of the iliac crest. 



As more food enters the stomach its capacity is increased by lateral expansion 

 rather than by any elevation of its fundus or downward expansion of its greater 

 curvature. The normal tonic action of the gastric muscle is able to hold up the 

 meal against the action of gravity to the level of the cardiac orifice. 



When, as not infrequently happens, the normal muscular tonicity of the 

 stomach is lost, the bismuth meal is no longer held up against the action of gravity, 

 but at once sinks to the most dependent part of the stomach where it lies as in a 

 flaccid sac, and gives rise to a crescentic shadow which may reach down almost, or 

 even quite, to the level of the pubes. 



In gastroptosis, and in general visceroptosis, the whole stomach may be displaced 

 downwards without any great loss of its tonicity. 



During a " screen " examination after a bismuth meal, the peristaltic movements 

 of the stomach can be seen to pass in distinct wave-like indentations from left to 

 right along the greater curvature, and to increase in force as they approach the 

 pylorus. 



When the stomach is hypertrophied and dilated, as a result of pyloric obstruc- 

 tion, the peristaltic waves are more pronounced, and the bismuth shadow extends 

 well over to the right of the median plane, owing to the dilated pyloric antruin 

 and pyloric canal being carried over to the right, in front of the superior part of 

 the duodenum. The stomach tends, therefore, to lose its somewhat J -shaped 



